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Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis [Hardcover]

Daniel Carlat M.D.
4.7 out of 5 stars  See all reviews (3 customer reviews)
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Book Description

May 18 2010
IN THIS STIRRING AND BEAUTIFULLY WRITTEN WAKE-UP CALL, psychiatrist Daniel Carlat exposes deeply disturbing problems plaguing his profession, revealing the ways it has abandoned its essential purpose: to understand the mind, so that psychiatrists can heal mental illness and not just treat symptoms. As he did in his hard-hitting and widely read New York Times Magazine article "Dr. Drug Rep," and as he continues to do in his popular watchdog newsletter, The Carlat Psychiatry Report, he writes with bracing honesty about how psychiatry has so largely forsaken the practice of talk therapy for the seductive—and more lucrative—practice of simply prescribing drugs, with a host of deeply troubling consequences.

Psychiatrists have settled for treating symptoms rather than causes, embracing the apparent medical rigor of DSM diagnoses and prescription in place of learning the more challenging craft of therapeutic counseling, gaining only limited understanding of their patients’ lives. Talk therapy takes time, whereas the fifteen-minute "med check" allows for more patients and more insurance company reimbursement. Yet DSM diagnoses, he shows, are premised on a good deal less science than we would think.

Writing from an insider’s perspective, with refreshing forthrightness about his own daily struggles as a practitioner, Dr. Carlat shares a wealth of stories from his own practice and those of others that demonstrate the glaring shortcomings of the standard fifteen-minute patient visit. He also reveals the dangers of rampant diagnoses of bipolar disorder, ADHD, and other "popular" psychiatric disorders, and exposes the risks of the cocktails of medications so many patients are put on. Especially disturbing are the terrible consequences of overprescription of drugs to children of ever younger ages. Taking us on a tour of the world of pharmaceutical marketing, he also reveals the inner workings of collusion between psychiatrists and drug companies.

Concluding with a road map for exactly how the profession should be reformed, Unhinged is vital reading for all those in treatment or considering it, as well as a stirring call to action for the large community of psychiatrists themselves. As physicians and drug companies continue to work together in disquieting and harmful ways, and as diagnoses—and misdiagnoses—of mental disorders skyrocket, it’s essential that Dr. Carlat’s bold call for reform is heeded.

Frequently Bought Together

Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis + Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America + Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
Price For All Three: CDN$ 50.64


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"Unhinged is a searingly honest and articulate account of modern psychiatry's failure to think outside the box of psychopharmacology in treating patients." (Alison Bass, author of Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial,winner of the NASW Science in Society Award for 2009)

“A psychiatrist looks deeply into the mirror and takes stock of his profession and what it has become. Whether you are a patient, student, trainee, clinician, or “KOL” (key opinion leader”), this frank and insightful book will definitely make you think.” (Erick Turner, M.D., Department of Psychiatry and Center for Ethics in Health Care, Oregon Health & Science University)

"Unhinged provides crucial insights for anyone who cares about the future of Psychiatry. Must reading for psychiatrists and patients alike." (Keith Ablow, MD, author of Living the Truth)

"Terrific book, terrific insights! Daniel Carlat is the kind of psychiatrist we wish we all had." (Manny Alvarez, MD, Senior Managing Health Editor at Fox News Channel)

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Front Cover | Copyright | Table of Contents | Excerpt | Index | Back Cover
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1 of 1 people found the following review helpful
5.0 out of 5 stars Debunking myths of psychiatric medicine Dec 15 2012
By Meg
Format:Hardcover|Verified Purchase
I loved this very frank and forthright book on the way psychiatry is practiced in the current age. To me there was an extra level of interest, since I myself trained in medicine, and I worked in general practice for eight years before having to stop working due to severe depression. I have to agree with everything Dr Carlat has written, especially as to how the profession now mainly treats sypmtoms rather than causes. I spent years on a merry-go-round of various pharmaceutical cocktails such as what is described in the book, without any psychiatrist actually getting at the root cause of my depression. The risks he describes are all true and shamefully little discussed by prescribing psychiatrists - this book is a gold mine of information for the unsuspecting patient and I would recommend it to anyone who is considering treatment with a psychotropic medication.
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1 of 1 people found the following review helpful
4.0 out of 5 stars Unhinged Jan. 3 2012
By Rasper
Format:Hardcover
A very interesting review of the psychiatry profession historicaly & where it is today. Insight to challenges & changes for the future. A good read for anyone that has someone they know with any mental challenge or illness, or one that is in the mental healthcare profession.
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Format:Hardcover|Verified Purchase
The author speaks with kindness and empathy about many of his patients and feels that psychiatry could do much more for the people who seek it's help other than just writing out a prescription. He seems to fell the art of listening has dies within the field of psychiatry and that people may get better from their illness if more Psychiatrists would actually "talk" to their patients. A very good book!
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Amazon.com: 4.1 out of 5 stars  41 reviews
81 of 87 people found the following review helpful
5.0 out of 5 stars Saddly, psychiatrists are now just drug pushers Nov. 22 2010
By Gaetan Lion - Published on Amazon.com
Format:Hardcover
This is essentially a whistle blower reporting on the corruption of psychiatry by Big Pharma. Dr. Carlat went to UCSF med school in 1985 as psychiatry was rapidly transiting to psychopharmacology. He is practicing at Massachussetts General Hospital (MGH) where many of the key drug trials had taken place and where faculty members had received millions from Big Pharma to conduct such trials. He also used to accept Big Pharma's money ($30,000 in total, a very small amount relative to others) to lecture to pitch its drugs until his conscience regained the better of him. Thus, he had a front seat and was an active participant in psychiatry's' corruption. His confession is very insightful.

Carlat feels that psychiatry is in a state of crisis, as it has lost much credibility with the public. He mentions a recent Gallup poll that uncovered that only 38% of Americans trust psychiatrists, on par with chiropractors (36%) and even bankers (37%) and way below regular physicians (69%). There are several themes to Carlat's analysis of psychiatry devolution.

First, psychiatrists have given up on understanding their patients. They don't do psychotherapy anymore. They essentially just prescribe drugs (mainly anti-depressants). They now call themselves psychopharmacologists instead of psychotherapists. For psychotherapy, you have to go to a psychologist (who got a graduate degree in psychology, but did not go to med school, and is not allowed to prescribe drugs).

Second, psychiatrists overdiagnose their patients. Way too many children are overdiagnosed with ADHD and even bipolar disorder (the latter being often meaningless for young children). From 1994 to 2003, children and adolescent treated for bipolar disorder rose by 8,000%! The majority of cases are misdiagnosed. The psychological troubles are related to complex sociological problems the psychiatrists make no effort to understand. And, way too many adults are overdiagnosed with ADHD, social anxiety, and mild depression for what are often normal responses to the challenges of daily life.

Third, psychiatrists are overdrugging their patients. Psychiatrists too readily prescribe anti-depressants and stimulants to treat just about any small psychological discomfort that could better be resolved through just a few therapy sessions.

Fourth, the efficacy of most drugs are highly questionable because they are based on an unproven scientific hypothesis: the brain chemical imbalance theory (called "monoamine hypothesis"). Carlat states that chemical imbalance is a myth perpetrated by the profession. Depression is explained by a deficiency in the neurotransmitter called serotonin. The problem is that the causal link between serotonin level and depression has never been proven. Actually, several studies attempting to prove this link ultimately served to disprove it. Therefore, SSR anti-depressants aimed at boosting serotonin levels work no better than placebo. In 50% of drug trials, the drugs do not beat placebo. Another outstanding book on this subject is: The Emperor's New Drugs: Exploding the Antidepressant Myth.

Fifth, psychiatrists understand very little regarding the human brain. Its functioning at the neurobiological level remains a mystery. Additionally, "to a remarkable degree our choice of medication is subjective, even random" acknowledges Carlat.

Sixth, so far technological innovations within psychiatry have failed. Innovations such as the vagus nerve stimulator, transcranial magnetic stimulation have been complete failures. Yet, they have been approved by the FDA only to be rejected by more serious studies.

All those themes have a common root: economic conflict of interest. About three decades ago, psychiatrists noted that they could make a lot more money by prescribing drugs instead of conducting therapy. A therapy session takes an hour. During this same hour, a psychiatrist can see three patients, quickly diagnose them and give them a prescription. As a result, psychopharmacology is far more lucrative and efficient than psychotherapy. The increased efficiency translated into lower claim cost per patient. Therefore, insurance coverage became more generous for drugs than for therapy. This only accelerated the transition to psychopharmacology.

Carlat suggests there are two major problems with this transition to psychopharmacology. First, it does not work that well. Many studies have confirmed that psychotherapy works often better than drugs and with no side effects. The relapse rate is lower as patients learn lifelong solving skills. And, second psychopharmacology has turned psychiatry into the marketing arm of Big Pharma. Now, over 27 million Americans are on anti-depressants that work little better than placebo but with side effects. Big Pharma spends twice as much on marketing as research. Carlat states that all the "new" drugs work no better than the original ones of 50 years ago. They are just a lot more lucrative because they are under patent. Antidepressants often bring in between $1 billion to $5 billion in annual revenues.

The conflict of interest in psychiatry have reached a critical level whereby the credibility of the profession is being questioned. Dr. Carlat covers the practice of drug reps and leading psychiatrists receiving millions of dollars from Big Pharma to give speeches to other doctors pushing their drugs and even testing their drugs in clinical trials. Psychiatrists lead the pack of specialties receiving the most money from Big Pharma. How can a clinician objectively evaluate a drug when he is paid a fortune by the developer of that drug? This is an egregious conflict of interest resulting in poor science and perpetrating the ignorance of psychiatrists. How can they figure what really works since they can't trust the original studies.

In the last chapter, Carlat makes recommendations to reform the field of psychiatry. He feels psychiatrists should not be trained through traditional med schools. They waste several years learning everything they will never need (radiology, surgery, delivering babies, ER training, etc...). And, they learn very little of what they really need such as therapy. Instead, he refers to a prototype program in San Francisco that offered a special degree in mental health that combined extensive training in therapy and pharmacology. It prepared students far better than the long curriculum of med school. Yet, the program was killed by the psychiatry lobby. Carlat, similarly, feels we should license all psychologists to prescribe drugs after providing them additional training in pharmacology. He also feels that all psychiatrists should conduct therapy as they did in the past.

Carlat's recommendations make sense. But, the psychiatry lobby will resist all such proposals to protect their income. Nevertheless at the risk of becoming ostracized by colleagues, Carlat is really courageous for stating what is necessary to restore integrity to his profession.
61 of 69 people found the following review helpful
5.0 out of 5 stars Honest, Courageous, and Accurate May 24 2010
By Bret A. Moore - Published on Amazon.com
Format:Hardcover
Dan Carlat's Unhinged: The Trouble with Psychiatry is a brutally honest account of the gaps in understanding psychiatric illnesses, the relative lack of knowledge about the actions and effects of psychiatric medications, and the importance of psychotherapy. This book should be required reading for all psychiatry residents and psychiatry faculty and on the bookshelves of both early and late career psychiatrists. It is also a must read for clinical psychologists training to prescribe. Prescribing and Medical Psychologists do not want to make the same mistakes that lead psychiatry to where it is today.

Bret A. Moore, Psy.D., ABPP
27 of 29 people found the following review helpful
5.0 out of 5 stars A Must Read for Mental Healthcare Providers Aug. 16 2010
By Steve Clancy - Published on Amazon.com
Format:Hardcover|Verified Purchase
The spotty record of the efficacy for psychotropics comes as no surprise, I have seen this on a daily basis for 20 years. But, the degree of deceit and fraudulent behavior by pharmaceuticals was astounding (why I should be so astounded is beyond me). This is a well written book, readable, sensible and helpful. His recommended solution to the problems with psychiatry are totally sensible, although its not likely at this time I would want to go back for the training needed.
13 of 14 people found the following review helpful
4.0 out of 5 stars Honest, introspective look at author's profession Aug. 6 2010
By J. Davis - Published on Amazon.com
Format:Hardcover
Something is rotten in the state of psychiatry today, and Daniel Carlat shows you, with brutal honesty, what the problem is. He shows the influence of the drug companies over doctors--even over himself at one point, which I give him credit for admitting. Several big names in psychiatry--including Daniel Amen--are shown to be quacks. Studies funded by drug companies turn out to be--shockingly!--biased and unreliable. Yes, as many reviewers have pointed out, drug company influence over doctors is hardly breaking news, but sometimes an important message needs to be repeated over and over again. At the end of this book, you'll like Dr.Carlat, but you may be weary of that Paxil pill your doctor just prescribed. If you're a mental health professional or patient, you need to read this delightful book.
6 of 6 people found the following review helpful
2.0 out of 5 stars Carlat Condemns the Industry, but Continues to Prescribe Drugs that May Harm May 23 2013
By Robert Olshansky - Published on Amazon.com
Format:Hardcover|Verified Purchase
"Unhinged" describes and documents how Big Pharma has undermined and corrupted the practice of psychiatry by relentlessly marketing drugs which are of questionable value and may even be harmful to many patients. The book provides an insiders view of the industry written by a highly-regarded psychiatrist. It is truly shocking how lax the FDA approval process is, and how corrupted the profession of psychiatry has become.

As one very revealing example, Carlat discusses how lax and ineffective the FDA process is for approval of psycho-active drugs. He sites (p 116-117) a study by E. Turner et al (New Eng. J. of Medicine, 2008) that analyzed all the clinical studies of 12 antidepressants approved by the FDA from 1987-2004, which included all the widely used SSRIs. Of 72 studies submitted to the FDA, 38 were positive and 36 showed negative or questionable results. And the ones that are "positive" typically show that the drug under test is only somewhat better that a placebo. The bottom-line is that while tens of millions of patients take these drugs, if one looks at all studies combined there is no real scientific evidence that these drugs are better than placebos.

Furthermore, all of the above studies are relative short duration clinical trials. In his excellent book "Anatomy of an Epidemic", Robert Whitaker points out that very few long-term studies have been carried out. Chapter 8 of Whitaker's"Anatomy" reviews the studies that have been done of long-term outcomes of patients who have taken antidepressants and basically concludes that unmedicated patients have better long-term outcomes than medicated patients, and the long-term prognosis for medicated patients is very poor. Whitaker provides convincing evidence that the rapidly growing population of chronically depressed patients is actually caused by the widespread use of anti-depressants.

While one can applaud Carlat for his strong condemnation of the pharmaceutical industry and the corruption of psychiatry, it is also somewhat shocking that Carlat himself continues to prescribe antidepressants to his patients. Throughout the book Carlat provides personal anecdotes of various patients that were "helped" by antidepressant medication. But surely he knows that the short-term benefits he describes could easily be due to the placebo effect, and he offers no knowledge ( and probably has none) of the long-term outcomes for any of these patients.

Carlat is obviously very aware of the inadequacies of the existing clinical studies, of how the "placebo effect" misleads both patients and psychiatrists into thinking that these drugs are having a positive effect, but yet he continues to prescribe them. He candidly explains how the medical insurance payment practices reward psychiatrists for 15 minute medication sessions, and how his income would be reduced by as much as 50% if he practiced traditional psychotherapy with 45-50 minute sessions.

To Carlat I say: "Physician, heal thyself".

To potential readers, I say, read "Unhinged", but also read Whitaker's "Anatomy of an Epidemic" to learn the true extent of the destruction being caused by the widespread used of psycho-active drugs.

Disclosure: I should note that I have no personal connection to the healthcare industry, have never taken psychoactive medications, nor had a mental illness. I write this review because I am shocked by the negative impact the widespread use of psychoactive prescription drugs has on our citizens, and the enormous economic cost it imposes on our society both in terms of the direct cost of the drugs, but on the ongoing costs of caring for people whose lives have been chronically impaired by their use.
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